Respiratory Medicine Case Reports 20 (2017) 133e136 Contents lists available at ScienceDirect Respiratory Medicine Case Reports journal homepage: www.elsevier.com/locate/rmcr Extra-corporeal membrane oxygenation as an indispensable tool for a successful treatment of a pregnant woman with H1N1 infection in Brazil s de Souza Dantas a, c Rodrigo T Amancio a, b, *, Celina Machado Acra a, Vicente Ce a b c Intensive Care Unit, Hospital e Maternidade Santa Lúcia, Rio de Janeiro, Brazil ~o Oswaldo Cruz, Rio de Janeiro, Brazil rio de Pesquisa Clínica em Medicina Intensiva, Instituto Nacional de Infectologia - Fundaỗa Laborato rio Clementino Fraga Filho, Universidade Federal Rio de Janeiro, Rio de Janeiro, Brazil Intensive Care Unit, Hospital Universita a r t i c l e i n f o Article history: Received 18 September 2016 Received in revised form January 2017 Accepted January 2017 Introduction Influenza A (H1N1), described as epidemic in June 2009 [1], was declared the first pandemic of this century, due to reports of high morbidity and mortality, and sustained transmission in many countries [2e4] Alerts about the increased risk factors (e.g., pregnancy, coexisting diseases, childhood, age, and inability to perform self-care) were also assessed Physiological and anatomical changes that occur during pregnancy can affect the known clinical presentation of respiratory signs and symptoms, masking the adequate diagnosis, and delaying the treatment [5,6] In addition, pregnancy may increase the risk of severe influenza-associated complications, supporting to the recommendation to promptly treat pregnant women with H1N1 infection [7] In severe cases of Influenza A (H1N1) infection, admission to an intensive care unit (ICU) is recommended Approximately 9e31% of the hospitalized patients were admitted to an ICU, with a mortality rate ranging from 14 to 46% [3,4,8,9] From July 2009 to January 2, 2010, 44,544 cases of the disease and 2051 deaths were reported in Brazil [10] H1N1 infection is therefore a possible cause of acute respiratory distress syndrome (ARDS) The prevalence of ARDS during pregnancy has been estimated as 16 to 70 cases per 100,000 pregnancies [11] Non-obstetric causes of ~o Sal* Corresponding author Hospital e Maternidade Santa Lúcia Rua Capita ~o, 27, Humaita , Rio de Janeiro 22271-040, Brazil oma E-mail address: amancio.rt@gmail.com (R.T Amancio) ARDS include sepsis, intracerebral hemorrhage, blood transfusion, trauma, and also H1N1 infection Overall mortality for both the mother and fetus is high, and significant morbidity can persist even after recovery Mortality due to ARDS during pregnancy is not significantly different than that in non-pregnant patients (23%e 39%), and is associated with marked perinatal morbidity and a high rate of fetal loss (23%) [11] Treating ARDS during pregnancy follows that for the general population and includes providing supportive care while identifying and treating the underlying cause Once conventional lungprotective mechanical ventilation fails, alternative approaches including the use of high-frequency oscillatory ventilation, lung recruitment maneuvers, prone positioning, and inhaled nitric oxide can be used, without reducing mortality in the general population [11] However, strategies commonly used in non-pregnant patients might not be acceptable during pregnancy [12] Extracorporeal membrane oxygenation (ECMO) can be used in patients with ARDS and refractory hypoxemia as salvage therapy [13] The benefit of ECMO over lung-protective strategies using conventional ventilation remains controversial [14,15], and there are no high-quality data on its use in pregnancy Observational data from the 2009 H1N1 pandemic suggested that ECMO may play a crucial role in younger patients with refractory hypoxemia resistant to conventional lung-protective mechanical ventilation strategies [16] Here, we report the maternal clinical course, treatment, and fetal outcome of an H1N1 infected pregnant woman with severe outcomes, and the successful use of ECMO Case report Previously healthy 30-year-old white Brazilian woman (G1P0), at 27 weeks of gestation, attended in the emergency department with a 5-day history of progressive dyspnea, lethargy, and fever Clinical examination revealed a gravid uterus, consistent with gestational age, initially treated as bacterial pneumonia, with coverage for H1N1 (Amoxicillin plus Clavulanate 1g TID (three times a day), Clarithromycin 500mg BID (twice daily), and http://dx.doi.org/10.1016/j.rmcr.2017.01.015 2213-0071/© 2017 The Authors Published by Elsevier Ltd This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) 134 R.T Amancio et al / Respiratory Medicine Case Reports 20 (2017) 133e136 Oseltamivir 75mg BID, after allocated in ward She had no auscultatory findings, and chest X-ray showed consolidation in the base of the left hemithorax (Fig 1a) Fetal ultrasound had no alteration About hours after hospitalization, due to worsening of dyspnea, associated with an increased demand of supplemental oxygen, the patient was transferred to the ICU, and started continuous non-invasive ventilation (NIV) using a full-face mask (10 L/min O2) Since there was an unsatisfactory clinical and laboratorial response after hours under NIV, we chose for elective endotracheal intubation After 12 hours of ICU admission, the patient presented severe hipoxemia, (PaO2/FiO2